A Chance to Cut is a Chance to Cure

A perspective on medical and other issues from a general surgeon

Monday, September 20, 2004

Popularity of Surgery....In the September 20 issue of Newsweek the recent interaction of President Clinton with the business end of an operating room is used to bring attention to the changing perceptions of surgery as a career: A New Style in the Operating Room

Under the lights of his operating room at New York Presbyterian Hospital, heart surgeon Dr. Craig Smith looks like a futurist, using high-tech robotic techniques on elderly patients once deemed too fragile for major surgery. Outside the OR, he's pure old school, with a deadpan wit and a schedule of 16-hour days. A college running back, he says he copes with stress by "keeping my emotions canned up and focusing on the job." To perform a "relatively routine" quadruple bypass on former president Bill Clinton last week, Smith postponed his 34th-wedding-anniversary vacation. He's just what Americans picture when they think of a surgeon: brilliant, stoic, workaholic and male.

In the near future, surgeons like Smith may be the exception, not the rule. Since 1999 surgery has attracted about 5 percent of medical graduates—down dramatically from the 12 percent it pulled in the '80s and '90s, when the best and brightest students saw it as both intellectually enriching and, well, enriching. Surgical insurance premiums began to climb in the late '90s, making the field look a lot less lucrative. In some areas of the country, premiums have doubled or more since 2000, with surgeons paying well over $100,000 annually just to stay in business. Meanwhile, in an effort to boost enrollment and create a generation of doctors (particularly surgeons) who were more than technically proficient geeks, medical schools started recruiting a new kind of student—someone more laid back, with interests outside work. And they've succeeded: lifestyle-friendly specialties like radiology, orthopedics and dermatology are thriving. Anand Rughani, a third-year student at McGill, was toying with surgery but will probably choose neurology instead. Surgery "is so demanding," he says. "It can change your values. With lawsuits, you treat things fairly aggressively for fear of not doing something. Maybe surgery isn't the best thing for the patient, but that's what you end up having to do."

In fact, that cuts both ways. Sometimes you can be faced with a situation of a patient dies regardless. Under those circumstances one may be reluctant to offer the procedure. The match for surgery actually hit bottom in 2002 when of the 1039 positions offered, only 782 were filled by U.S. graduates and only 981 slots were filled overall. But the data also shows that roughly half of the family practice and internal medicine positions are filled by U.S. graduates. But there are more slots offered for IM and FP, and more family physicians and internists out there. The medical establishment looks to recent changes to try and stem the tide:

Medical schools are struggling mightily to bring students back to the OR with promises of a kinder, gentler professional future. New rules established last year dictate that medical residents can work a maximum of 80 hours a week—far fewer than the 120 hours traditionally demanded by surgery residencies—and courses in bedside manner are now mandatory in many curricula. The old guard isn't necessarily happy. "It's difficult to explain to my generation, who worked 120 hours a week, how people with two thirds as much training are going to get the same experience," Smith says. Duke University's surgery program was put on probation in June, partially for a citation related to lax enforcement of the 80-hour workweek.

Such "reforms" will take years to bear fruit, if any is to be had. One problem that may rear its' ugly head in the near future is what to do if residents are not getting a sufficient number of cases. In order to sit for the boards a surgical resident must perform a certain number of cases over the five clinical years of their residency. If the amount of time spent in the hospital is reduced by 1/4 to 1/3, there can be problems obtaining the required experience.
Alternatives would include either reducing the number of cases required, eliminate the workhour limits, or prolong the length of the residency. The first option would not serve the surgeon or patient well, the second would not pass muster with the ACGME, and the last would take an already long residency and lengthen it further. That would do little to entice the "laid back" student with "interests outside of work" . The effects of this aren't likely to be seen for several years

As the boomers age, demand is likely to increase—just as today's young surgeons, accustomed to lighter schedules, start taking senior positions. Smith, at 55, toils as many hours as residents do. "If you like the work, it's tolerable," he says. But if you want your anniversary off, maybe you should go into neurology.